A postoperative complication: Untangling iatrogenic rotation at the ligament of Treitz

Abstract

Iatrogenic small bowel obstruction is rare. Cases of proximal small bowel obstruction caused by the rotation of the distal duodenum around the ligament of Treitz are even rarer. Only a few instances of iatrogenic small bowel obstruction have been reported, and these have involved the distal small bowel due to bowel entrapment in sutures, iatrogenic defects in the mesentery or omentum, and retained foreign body. This report describes a case of proximal small bowel obstruction caused by iatrogenic rotation of the distal duodenum around the ligament of Treitz following an open right-radical nephrectomy. The patient had an initial open right radical nephrectomy with delayed postoperative recovery, presenting with abdominal pain and vomiting. Serial CT imaging revealed proximal small bowel obstruction with rightward displacement of the duodenojejunal flexure. A diagnosis of iatrogenic rotational malposition of the proximal small bowel was made, requiring surgical intervention to relieve the obstruction. This case emphasizes the importance of carefully evaluating the proximal small bowel on postoperative imaging, ensuring the duodenojejunal flexure remains in its anatomical left-sided position. Such cases of altered postoperative anatomy and delayed recovery further emphasize the role of diagnostic radiology in problem-solving and guiding patient management.

Keywords

• Small bowel obstruction
• Ligament of Treitz
• Duodenum
• Rotational variation, Nephrectomy
• Postoperative complications